Non-Opioid Tx Beats Hydromorphone for Migraine Pain Relief in the ED

The primary outcome of sustained headache relief

Intravenous prochlorperazine plus diphenhydramine was found to be superior to IV hydromorphone for the treatment of migraine pain in the emergency department setting, according to a new study published in the journal Neurology.

The double-blind study was conducted at 2 emergency departments (ED) in New York City. Participants were randomized to either hydromorphone 1mg (n=64) or prochlorperazine 10mg plus diphenhydramine 25mg (n=62). Diphenhydramine was administered in order to prevent akathisia, a side effect of IV prochlorperazine.

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The primary outcome of sustained headache relief (mild or no headache within 2 hours of drug administration maintained for 48 hours) was achieved by 60% (n=37) of patients in the prochlorperazine group versus 31% (n=20) of patients in the hydromorphone group (difference 28%, 95% CI 12–45, number needed to treat 4, 95% CI 2–9).

“Ours is the first randomized study to demonstrate that it is not appropriate to administer the opioid, hydromorphone, as a first line therapy for patients with migraine,” said lead researcher Benjamin Friedman, MD, MS, who is also Professor at Albert Einstein College of Medicine and Vice-Chair for Clinical Investigation in the Department of Emergency Medicine at Montefiore.

The researchers followed up with the study participants at 48 hours, 1 and 3 months after their ED visits and both groups had similar long-term outcomes, including comparable number of headache days and return ED visits. Dr. Friedman said, “Our study clearly shows there is no benefit to using the opioid hydromorphone as first-line treatment for most migraine patients in the ED.”